(Photo courtesy of Sweet Brook Massage Spa)
A 2024 systematic review of 17 systematic reviews found that the evidence and certainty of massage therapy for 13 pain conditions to be predominately “low” or “very low.”
“There were only a few conditions for which [the] authors of systematic reviews concluded that there was at least moderate-certainty evidence regarding health outcomes associated with massage therapy and pain,” the researchers wrote.
These moderate-level pain conditions include: Post-breast cancer surgery, chronic low back pain (with myofascial release (MFR)), chronic low back pain with short-term effects, labor pain (with acupressure), low back pain (with physical therapy), myofascial pain, and fibromyalgia (with MFR).
Other conditions that were ranked low or very low include:
- Cancer-related pain
- Back pain (chronic back pain with tui na and in the medium term)
- Chronic neck pain
- Mechanical neck pain
- Palliative care needs
- Plantar fasciitis
- Post–breast cancer surgery pain
- Postcesarean pain
- Postpartum pain
- Postoperative pain
(See chart for a complete breakdown)
The researchers, led by Dr. Selene Mak of Veterans Affairs (VA) in Los Angeles, concluded that reasons for such low ratings are a combination of:
- Inconsistent comparison groups
- A lack of clarity in the definition of massage therapy
- Sham massage therapy (e.g. light touch) can still have symptom benefits and is not inert like a placebo pill
In one example, the researchers wrote that acupressure was sometimes called acupuncture or massage therapy in some studies.
“In this case, we reviewed and included only publications that were explicitly labeled acupressure and did not review publications about acupuncture only,” Mak and her colleagues wrote. “This highlights a fundamental issue with examining the evidence base of massage therapy for pain when there is ambiguity in defining what is considered massage therapy.”
Regarding sham therapy, they questioned whether such placebo treatment is an appropriate comparison group. “The priority should be studies comparing massage therapy with other recommended, accepted, and active therapies for pain,” the researchers wrote. “Studies comparing massage therapy with other recommended therapies should also have a sufficiently long follow-up to allow any nonspecific outcomes (e.g. those associated with receiving some new treatment) to dissipate.”
The long-term follow-up should be at least six months, they recommended.
“This is a challenge given that massage, like other complementary and integrative health interventions, does not have the historical research infrastructure that most health professions have,” the researchers wrote. “Nevertheless, it is only when systematic reviews and meta-analyses are conducted with high-quality primary studies that the association or lack of association of massage therapy with pain will reach higher certainties of evidence.”
Mak and her colleagues said in an interview with Massage & Fitness that there are several challenges with massage therapy research. These include
- Defining what the medical massage therapy intervention consists of such that, if found to be effective, it can be reproduced with fidelity by others
- Controlling for nonspecific effects. Placebo control is not practical for massage, so figuring out what the comparison is going to be is a challenge.
- Blinding both the person receiving medical massage therapy and the provider delivering medical massage therapy is challenging to meet gold-standard RCT approaches. Appropriate comparison trials to standard care are alternatives.
What does this mean in practice?
While this appears that massage therapy may not have much benefits for chronic pain, Mak and her colleagues said that low to moderate-quality evidence does not mean that the approach is not effective.
“Rather, this indicates that the quality of the research does not reach the highest level of certainty,” they said. “A low to moderate level of evidence also means that from what has been shown to date, medical massage therapy may (for low certainty evidence) or probably (for moderate certainty evidence) has a benefit for those conditions. Additionally, medical massage therapy is considered a low-risk intervention, and therefore, even low certainty of evidence of a modest benefit may be sufficient to make the risk/benefit assessment favorable.
Mak and her colleagues suggested that medical massage therapists and other care team members could apply their research in their treatment planning for veterans and other patients with similar conditions.
“The team can also communicate to patients as a part of treatment planning that medical massage therapy may be appropriate for conditions, such as chronic low back pain, fibromyalgia, labor pain, post-breast cancer surgery,” they said, adding that their research has found some evidence to support massage therapy’s effectiveness for such conditions and limited for others.
Mak and her colleagues used an evidence map that was established by the Veteran Affairs in Los Angeles in 2016.
They described the evidence map as a type of systematic review that examines a wide area of research to show what evidence exists, where there are missing pieces, and what still needs to be studied.
To help guide decisions by policymakers and healthcare providers, the VA asked for a new evidence map using studies published since 2018 to help answer a key question: “What is the certainty of evidence in systematic reviews of massage therapy for pain?”
The VA’s evidence map examines several key features of each massage systematic review:
- Number of studies in a review
- Type of pain condition
- Type of intervention
- Strength of the findings
- Outcomes associated with massage therapy
The evidence map does not critically analyze or break down how effective treatments are for specific conditions; rather it is useful for spotting research gaps and guiding future studies, the researchers wrote.
They addedr that the massage therapy research and education “would be best advanced by educating the wider research community with clearer definitions of massage therapy and whether it is appropriate to include multiple modalities in the same systematic review.”
“Risk of bias is not normally a term used to describe a systematic review, Mak and her colleagues said. “Risk of bias is most often used to describe individual studies. In this case, the authors of the included systematic reviews would have performed a risk of bias assessment on the individual studies in order to implement GRADE (i.e., rated strength or certainty of evidence). VA did not re-do these assessments and recorded the rating of evidence as reported in the included systematic reviews.”
Mak and her colleagues said that medical massage is part of the VA’s medical benefits package. “Referring clinicians require quick ways to evaluate the evidence in order to incorporate medical massage therapy into a veteran’s treatment plan,” they said. “This is a way for the clinicians to quickly understand the state of the literature for this service and appropriately refer veterans for conditions expected to respond to medical massage therapy.”
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s in graphic communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
